Health History Form working

In order to provide you the best possible wellness care, please complete this form*

*Please note that this form is optimized to look the best at 800x600 screen resolution. If you are experiencing alignment issues with any of the elements of this form, please adjust your screen resolution accordingly. Thank you.

Patient Data

Mailing Address

Your Health Profile

Please answer the following lifestyle questions

Reason For Visit

If you have a specific complaint for which you are seeking care please answer the following questions:

Is your current complaint the result of a specific injury? If yes, please indicate what type:

Insurance Information

*If an auto accident, please provide:

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from any of the following:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Enter the verification code in the box below.